Addressing Nepal’s Hidden Health Challenge: Depression

Self-harm is the leading cause of death for individuals 15-49 years old in Nepal.[i] Nepal has the 2nd highest rate of DALYs (disability adjusted life years) caused by depression in the world, trailing only the United States.[ii] Estimates of the prevalence range of Major Depressive Disorder (MDD) and anxiety range from 18.4%[iii] to 37%.[iv] About 10% of women suffer from postpartum depression.[v] Prevalence of MDD and anxiety in Nepal is highest among displaced people (those who can no longer live in their homes, usually due to violence or other unsafe circumstances) and survivors of traumatic events such as the 1996-2006 Civil War. A particularly dramatic 2003 study of 290 internally displaced individuals found prevalence rates of each condition to be about 80%.[vi] The highest prevalence rates are in rural mid-Western Nepal where the Nepalese Civil War fighting was the worst and many tortured survivors now live.[vii] Indigenous individuals and those in lower castes have higher depression rates.[viii]

There are many risk factors for MDD and anxiety in Nepal, including poverty, illiteracy, a low education level, living in a conflict area, and experiencing disaster.[ix] Also, alcoholism and MDD are comorbid – among alcohol dependent individuals, the lifetime prevalence of MDD is 45%.[x] Among women, the risk factors for MDD are unique and particularly are related to how safe and happy they feel at home. If women don’t feel safe at home, they’re much more likely to have a mental illness.[xi] In Nepal, 21% of men believe wife beating is justifiable,[xii] which perpetuates domestic violence. Women’s depression is also strongly correlated with one’s husband’s alcoholism, polygamy, having many children, smoking, and stressful life events.[xiii] Accordingly, housewives have the highest suicide rate.[xiv] Similarly, the unemployed, impoverished, and marginalized in society are more at risk for mental illness, suicide, and alcoholism – they’re more likely to have low self-esteem and feel as if they have a low level of social capital and agency.[xv]

Repairs are conducted on a health clinic in rural Nepal. Photo courtesy of Possible Health Organization

The economic burden of mental illness falls almost exclusively on one’s family. On average, a Nepalese worker makes 100 rupees a day ($1.15 USD).[xvi] Yearly, the cost of caring for a mentally ill family member is 25,000 Nepalese rupees (about $375 USD).[xvii] This cost can trap a family in the cycle of poverty. Further, depression is associated with decreased national economic productivity; workers who are depressed have higher rates of absenteeism, are less productive at work, take more sick-days, and file more disability claims.[xviii]

To address this significant challenge in Nepal, it is imperative that Nepal reforms its health system to address mental illness and alcohol addiction. The law still defines mental illness as madness and there is no legislation dictating proper care and treatment of individuals who are mentally ill.[xix] In the whole nation there are only 32 psychiatrists, 6 psychologists, and no social workers.[xx]

While less than 15% of people who commit suicide seek help from government services, more than 40% consult traditional healers.[xxi] One strategy is to improve these traditional healers’ capacity to provide more modern therapy and medical techniques in conjunction with their traditional practices. They’re already trusted individuals in the community; therefore, by task-shifting to them and rural nurses, the nation can enhance access to services. The National Institute on Mental Illness explains that 45-98% of treatment costs are offset by an employees’ increased productivity,[xxii] which means this treatment is cost effective

Furthermore, a national education campaign about what MDD, anxiety, and alcoholism are, how to address them, and where to seek help may help give people access to care as well as challenge traditional conceptions about their causes. Destigmatization is the first step in change. Similarly, the establishment of group therapy is beneficial and free if established on a community basis. Finally, it may reduce MDD and anxiety for doctors and trusted health care professionals to provide short, targeted counseling sessions to provide individuals with resources about their options for recovery and to delineate the harms of alcohol abuse.[xxiii] Change is possible, but only if Nepalese lawmakers openly acknowledge the harms of MDD and anxiety and take strong, rapid steps to reduce its prevalence and harms.